Colin from Portland has written a very nice article on the differentiation between acute pain and chronic pain today on Hurt.com Here is a link to the article: Acute Pain vs. Chronic Pain.

Interesting research coming out of the annual meeting of the American Academy of Pain Medicine. Based on their most recent research, thoughts of fear, catastrophe, and depression are likely to contribute to acute pain becoming chronic pain.

Sean Mackey, MD, PhD, chief of the pain management division at Stanford University, commented, "Those who had more fear during an acute low back pain episode were much more likely to ultimately over-predict the amount of pain they had, which ultimately led to significant increase in fear-avoidance behaviors, with subsequent worsening of symptoms, increase in duration of pain, and increase in disability." Also, patients with depression and anxiety are 2-5x more likely to develop chronic pain one to eight years in the future.

One final interesting statistic is tha there are 34 million surgeries that take place each year. 10% of patients who undergo sugery will develop chronic pain. That's 3 million additional pain sufferers each year!

With Elizabeth Taylor's death this week, there has been significant discussion about end of life pain management and the use of pain killers. During her life, Taylor suffered many injuries, skin cancer, scoliosis, and 30 surgeries, before eventually succumbing to congestive heart failure.

ABC News has done a nice piece on the "Double Effect" or Taylor's challenge of using pain killers at the end of life when overuse or improper use of pain killers can actually hasten death. Many pain killers like morphine and benzodiazepines are prescribed to alleviate the pain caused by medical conditions, BUT can actually make it harder to breathe, causing death in some instances. Use of pain killers at the end of life is defended by many doctors. Proper use of pain killers at the end of life can reduce pain so that pain sufferers can properly say goodbye to their loved ones.

Three doctors had been accused of overprescribing pain medication in 1990 to help Taylor manage her back pain.

Soccer Injury, Aquila, FlickrIf this seems like a simple topic, forgive my naivete. But I believe this is a very critical distinction to make and one that I failed to for a long time. This distinction is important because it can define how you are treated by medical providers and in turn dictate how you perceive it your injury/condition.

Chronic pain/injury/disease is something the progresses slowly, develops over time, and becomes a systemic issue often gathering momentum as it progresses. The cause and effect relationship is generally unclear.

Acute pain/injury/disease is something that has a rapid onset, short duration and often times (but not always) a result of a specific impact or traumatic event to the body. The cause and effect relationship is generally pretty clear.

These are generalizations of course, and there is much more nuance to be had. But for me, getting to these basic classifications more quickly would have gone a long way.

As an 18 year old I was injured playing soccer when I collided with a goalkeeper. To spare you the melodramatic details the end result was a trip to the Emergency Room, a referral to an Orthopaedic Doctor and a little physical therapy. There were some mumblings about hyperextension, cervicalgia, and contusions but nothing definitive. I was supposed to be fine. Nothing was broken or dislocated and plus I was 18, an athlete and in the prime of my health.

Unfortunately this has not been the case. I write this seven years later with much worse pain than at initial onset and an unclear future. But one thing I see looking backward is a fundamental misunderstanding of chronic vs acute pain.

For years I pursued treatments that were more appropriate for acute problems. I told people that this specific injury was the source of my problems. I saw the same chiropractors and therapists over and over. I wondered why I wasn’t healing. I blamed myself for not healing. I wondered how such an innocuous seeming injury could be so devastating. And I went in circles.

Now maybe I would have either way. But I do think that a considerable amount of time and energy was wasted on the wrong treatments and incorrect methods of thought. I now think of my problem as something that preexisted the “injury” and the “injury” simply gave an opportunity for the problem to manifest. I don’t advocate that everyone run out and demand some type of a diagnosis and throw around somewhat arbitrary terms like “chronic”. But a clear understanding of an injury or a medical condition is imperative.

My advice? Do a lot of research, don’t accept everything a doctor tells you, advocate for yourself, get multiple opinions, stay positive and most of all listen to your body.

Which brings me full circle to writing for Hurt.com. I am writing not from the perspective of an expert or someone with all the answers. If I had some type of panacea I would gladly give it to all of you, right now. Sadly I don’t have a panacea. I am simply someone who’s been through a lot and wants to share in the hope that my experiences can help others.

Hospital Team, ReSurge International, FlickrIn The Hospital, Down In The Dumps

Whenever a serious injury occurs to someone, there is often an associated feeling of being alone - even when family and friends are close by or still in the room with you. It may be a side effect of the drugs being administered to you or something to do with the injuries. Expressing your feelings can be difficult at an early stage of treatment and recovery, but can go a long way towards helping you deal with pain levels. Try to be more positive in outlook and not dwell on uncertainties to help keep your brain working in ways that diffuse and reduce pain.

Try to engage the hospital staff a little when your family and friends aren't around to keep your spirits up and to help avoid getting depressed about your situation. Should you already have issues with depression, let your nurses know about it if you haven't told any of the staff about it. The trauma center will have a variety of people available to help. You endured a physical trauma and are getting help - some help for mental trauma isn't beyond their scope or capability.

The Hospital Pain Management Team

At Harborview, there is an actual team of three doctors - two residents and an attending, who come around before surgeries proven historically to be painful and will go over the strategies in current use to help keep you from going over the pain edge. For me, it was the use of the standard intravenous pain meds with the addition of a femoral catheter block. This was inserted into my leg up at the inner thigh and threaded down to the nerves just above my knee to help block the pain signals that come from the repair sites below. From what I have read since about tibial plateau fractures, I'm glad they did the block. It's supposed to be one of the most painful recoveries imaginable without one.

The pain medications are not without side effects. Nausea is a big one for many people, including me. It took a couple of attempts at finding the right combination of pain reliever and anti-nausea drugs to work for me. The first attempts shut off my appetite and I continued to lose twenty five pounds of weight until we hit on the right mix. There is something to the old sage advice that a little extra weight isn't such a bad thing. Had I been at what I used to consider my ideal weight, I don't know how much weaker I would have become with my body using up more muscle instead of fat. Good thing I was a bit chubby, I guess.

The i.v. drip pain meds today have a controller that is a bit like the buttons used on "Jeopardy". Using this system taught me to identify the onset of pain when the medications would begin to wear off and the need to watch the clock to see how much time I would get from the dosage controller. It was set up to allow the patient (me) a dose every 15 minutes as needed, with one push of the button.

Pushing it more often or more times within the 15 minutes didn't work. This teaches one to pay attention to one's body signals, the machine and the clock.

Thanks to that infernal machine, I can now pick up on subtle clues that tell me it's time to grab some ice and Tylenol before the pain goes nuclear.

Stay On Top Of It

You may have had someone tell you about the difference in pain control when they either skipped a dose or waited too long to take something for the pain. It's true - heading it off at the pass, cowboy-style, does help keep it down to a dull roar. Once you let the pain get beyond control, it becomes much, much more difficult to reign back under to a manageable level.

Specifically, what I'm referring to is pain that started out as a twinge, a dull ache, or even a momentary pop, that then turns into a raging pain monster refusing to let go of your leg, arm, back,or whatever is ailing you. Keeping on schedule with RICE (rest, ice, compression, elevation) and your medications , as well as learning to identify the onset of serious pain and to deal with it in a timely fashion is the way to keep on top of it.

Don't Overestimate Your Strength

Before and after surgery you will be told what to expect in the way of recovery time estimates and how your progression though the different stages of recovery might go. The best advice I can impart to you at this point is to be acutely aware of weakness in the legs and back. You culd very easily injure another part of your body just when you need it the least.To enable my bones to start healing properly, I was non-weight bearing ( no weight whatsoever) on the repaired leg for three full months. After that, I was allowed gradual 25% weekly increases, while still using crutches. So, quads? What quads? The muscles that help stabilize knee joints were basically gone. I had to be extremely careful to not twist the leg when beginning to put some weight on it, and so should you if you find yourself in a similar situation. Yeah, it is necessary to push yourself a bit to improve and build strength, but don't be stupid about it. It takes time.

Here Comes Physical Therapy

In my case, the doctors had to bolt together a good portion of my lower leg.

Due to the high energy impact nature of the crash, the parts list of stainless steel screws, bolts and internal fixator was quite long, indeed (On more than one occasion, the x-ray techs at followup appointments missed getting a picture of the entire assembly since they rarely see one as big as the one that's a part of me now). A level VI (6) on the Schatzker scale tibial plateau fracture repair can have a high complication /failure rate, so physical therapy is no joking matter. You have to do it and do it correctly.

In order to keep your knee joint from freezing up and having significant loss of range of motion, many hospitals will start you on a CPM (continuous passive motion) machine right in the hospital bed. The idea is to get you moving the joint as soon and as much as possible before scar tissue starts to interfere with motion. The CPM machines kind of worked for me, allowing me to maintain a real range of about 48 degrees on the repaired leg. This in contrast to my other leg at 140 degrees.

When I started P.T. in earnest at the 48 degree point, every single movement was a challenge. I was still on crutches, non-weight bearing, with the hinged brace off for the sessions. Just doing simple stretches, then a few leg lifts was enough to have my leg remind me I was alive. (Yeow!) Looking back, it hurt but was absolutely necessary for me to be able to walk again without dragging my leg behind me. It took months, but I'm walking with only a small limp and can move my leg beyond 112 degrees. Not perfect, but I still have the leg.

Yay, Team !

You, your family, your doctors and nurses, and physical therapists all have to work together in order for a successful outcome after a major surgery or surgeries. Communication between everyone is a critical component to avoid relapses, re-injury or more surgeries. If you notice that something isn't working or there are differing opinions on how to proceed in your recovery, stop the show and hash it out. Get up to date information and make informed decisions. It's your body and you have the final say on what to do with it. It's your team and you are allowed to make substitutions where you deem appropriate.

Who likes to cook? I do most of the time. I vividly recall four years ago, rushing around in the kitchen to get breakfast on the table for my family. I wanted to make what we all consider a “Sunday” breakfast. Well, since at the time, my son was only one years old, I kept a baby safety gate up at the kitchen entry. I had the most wonderfully cooked breakfast made and ready to serve.

So, I like to believe I am not your average server. No, I am the ‘All mighty super mom super server’ right. I take not one, but two plates, one in each hand. I also have a tall cup of orange juice tucked inside my inner elbow on the right. If you can visualize that, I then attempt to step over the baby gate with two plates and a cup of orange juice in tow. The top of my right foot didn’t quite make it over the baby gate, and so I completely lost my balance. As I destabilized, there was no way for me to break my fall and since I was holding so much, my right shoulder had to break my fall. Ouch! My right shoulder slammed into the ground and the last thing on my mind was how much pain was to come from this injury.

I started to get chronic pain radiating through my right shoulder at night, it was sort of a burning sensation in the beginning. I noticed that my pain would come in waves. The pattern of when my pain would emerge was every few months. Since my pain was so seldom in the beginning, I found myself dismissing it or thinking it would just go away. After a year of having shoulder pain every few months, I noticed the pain occurrence had shifted to every month for a couple days long. I do not recommend ignoring chronic pain, or toughing it out, but that is what I did for the first two years and it was because my pain would come and go.

Mentioning my pain began one year ago at a regular yearly medical check-up with a Family Physician doctor. I brought up my concerns about my shoulder pain and surprisingly I didn’t get much response regarding a diagnosis. After my yearly medical check-up, I self referred to a Sports Medicine doctor to get an x ray of my shoulder. I remember being so excited when I went to see the Sports Medicine doctor. I thought, finally I am going to get a diagnosis and treatment options. X rays were taken, the doctor then told me that the x ray only shows bone, not tissue damage. So, I was told that nothing was fractured. That was good news to me for starters. However, I was told by this particular physician that the reason my pain would only surface a couple days a month is because of the water retention that women experience. She prescribed me a diuretic to decrease water retention. I chose not to try the diuretic she prescribed to me because I wanted the chance to look into Alternative therapies. I started reading books and doing a little research on Alternative therapies.

I started doing gentle stretches on my arm and shoulder, using smaller weights at the gym and naturally going easy on my arm. Over time, I notice my pain slowly decrease in frequency and duration. I also came across a sample of Tiger Balm, which created a cool, tingly sensation for pain relief. Tiger Balm is a balm made by a Chinese herbalist and is an analgesic remedy for pain relief. I found it to be a good product. Please check with your doctor before using Tiger Balm or any product though. To find out more information about this product, please visit: www.tigerbalm.com

WHY WRITE ON HURT.COM: I wanted the opportunity to share my experience with pain. I also wanted to share tips from how I dealt with pain. I believe there is more than one way to find pain relief and I believe in getting second opinions. Writing for hurt.com is a chance to share information, solutions, and to discuss the many remedies out there for pain relief. Although, I am highly interested in Alternative medicine, I do recognize the importance of seeing your regular Physician and taking medicationas necessary.